100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB3498

 

Introduced 2/16/2018, by Sen. Elgie R. Sims, Jr.

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/45.3 new

    Amends the Managed Care Reform and Patient Rights Act. Requires a policy or plan sponsor to notify the prescribing physician and the patient in writing 60 days before making a formulary change that alters the terms of coverage or discontinues coverage for a prescribed drug that the patient is receiving. Contains provisions for receiving the notice electronically. Provides that a policy or plan sponsor may provide the patient with the written notification, along with a 60-day supply of the prescription drug, at the time the patient requests a refill. Provides that nothing in the provisions prohibits insurers or pharmacy benefit managers from using certain managed pharmacy care tools so long as an exception process is in place allowing the prescriber to petition for coverage a non-preferred drug if sufficient clinical reasons justify an exception to the normal protocol.


LRB100 20562 SMS 35966 b

 

 

A BILL FOR

 

SB3498LRB100 20562 SMS 35966 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Managed Care Reform and Patient Rights Act
5is amended by adding Section 45.3 as follows:
 
6    (215 ILCS 134/45.3 new)
7    Sec. 45.3. Provision of notice; formulary changes.
8    (a) At least 60 days before making a formulary change that
9alters the terms of coverage or discontinues coverage for a
10prescribed drug that a patient is receiving, a policy or plan
11sponsor must, to the extent possible, notify the prescribing
12physician and the patient, or the parent or guardian if the
13patient is a child, or the spouse of a patient who is
14authorized to consent to the treatment of the patient. The
15notification shall be in writing and shall disclose the
16formulary change, indicate that the prescribing physician may
17initiate an appeal, and include information regarding the
18procedure for the prescribing physician to initiate the policy
19or plan sponsor's appeal process.
20    (b) As an alternative to providing written notice, a policy
21or plan sponsor may provide the notice electronically if, and
22only if, the patient affirmatively elects to receive the notice
23electronically. The notification shall disclose the formulary

 

 

SB3498- 2 -LRB100 20562 SMS 35966 b

1change, indicate that the prescribing physician may initiate an
2appeal, and include information regarding the procedure for the
3prescribing physician to initiate the policy or plan sponsor's
4appeal process.
5    (c) At the time a patient requests a refill of the
6prescription drug, a policy or plan sponsor may provide the
7patient with the written notification required under
8subsection (a) along with a 60-day supply of the prescription
9drug under the same terms as previously allowed.
10    (d) Nothing in this Section shall prohibit insurers or
11pharmacy benefit managers from using managed pharmacy care
12tools, including, but not limited to, formulary tiers, generic
13substitution, therapeutic interchange, prior authorization, or
14step therapy, so long as an exception process is in place
15allowing the prescriber to petition for coverage of a
16non-preferred drug if sufficient clinical reasons justify an
17exception to the normal protocol.